Assessing Client Progress

Running head: ASSESSING CLIENT PROGRESS 1

Introduction.

A progress note is a document which records the extent of treatment of a client’s progress in care and is mostly assessable by members of the treatment team. A privileged note on the other hand is a confidential documentation written by the therapist about the visit and unlike the progress note, it is only for the therapist and not assessable to members of the treatment team. The SOAP format- Subjective, Objective, Assessment, Plan is a type of framework used for writing out progress notes. This assignment aims at addressing the progress of a client seen in week 3 of my clinical with focus on the treatment modality and efficacy of treatment. A privileged note will be written to document progress of therapy sessions.

Part 1: Progress Note

The patient is an 18 year old Hispanic male KS, who is currently in high school. He is a first generation American with parents who emigrated from Mexico. He reports high anxiety most times especially in social situations. Patient also reports occasional depression and has had one inpatient psychiatric hospitalization due to suicidality in the past. He states he has been using marijuana a lot to cope with his anxiety but denies use of any other substances. Patient also reports non- compliance with his prescribed medications. He reports most of his anxieties stem from the fact that he is unaware of what next step to take when he graduates from high school and reports lack of motivation to continue. He states his family pressures him with talks about the future and college but he has no interest in going to college.

Modality of Treatment and Efficacy: Treatment for this patient involves use of medications as well as the use of cognitive behavior therapy (CBT) in addition to motivational interviewing. Motivational interviewing is often used as an adjunct to CBT in cases of anxiety disorder (Randall & McNeil, 2017). The goal of the treatment approach is to increase motivation especially in the area of sticking to therapy so that it can ultimately improve engagement and clinical outcomes. Patient became more engaged and receptive to accepting and contributing to the treatment plan.

Progress towards Agreed Goals: He became very engaged and receptive to accepting and contributing to treatment plan. He was instructed to continue his medications as prescribed

Modification of Treatment Plan: 0.5mg of Ativan was added to his medications to help patient with anxiety. This was to be used as needed BID and only a 15- day supply was prescribed.

Clinical Impression of Diagnosis: Anxiety disorders if left untreated has deleterious effects on the individual and societal levels (Randall & McNeil, 2017). Anxiety often co-occur with depression and the presence of their co-occurrence is related to a greater symptom severity, slower response to treatment and psychosocial disability (Gaspersz, Nawijn, Lamers & Penninx, 2018).

Changes from Original Assessment: Patient is more open to psychotherapy and has voiced an interest in having a male mentor due to his low motivation and social isolation. Also patient’s mother has agreed to oversee his medications to ensure medication compliance.

Safety Issues: He denies suicidality or homicidal ideation.

Clinical Emergencies: None

Medications: Celexa 10mg in the morning, Buspar 10mg TID, Ativan 1mg BID.

Compliance with treatment: Although patient has not been compliant with medications, he has shown willingness to commit to therapy.

Clinical Consultation: Patient has consulted his psychiatrist once every 2 weeks.

Collaborative Care: None

Therapist Recommendation: Recommendations are for patient to continue CBT with motivational therapy once a week. A mentor to check in with patient at least once a week, which patient states he is very open about due to his low motivation and social isolation.

Referrals: None at this time.

Issues related to Consent: Patient was informed about treatment plan and educated on medications and effects and there was no issue related to obtaining consent for treatment.

Part 2: Privilege Note:

Subjective:

KS suffers from anxiety and depression due to pressures to succeed/ go to college as well as feelings of being the “black sheep” of the family. Parents are immigrants from Mexico and do not understand why he should be mentally ill as it is viewed as a sign of weakness. All his brothers have either graduated from college or are in college. He fears the future and thinks he is a disappointment to all his family. He reports social isolation if possible as he gets extremely anxious and an increase in marijuana use.

Objective

Initially during therapy patient is observed to be very anxious, fidgety and sweating. He reports being dizzy and anxious. But as sessions went on and he became comfortable, patient was able to relax and be more open to therapy.

Assessment

KS has been attending individual therapy. Initially he stated “I don’t see how talking about these things will help”. When therapist addressed topics of motivation and introduced motivational therapy, patient became more interested. He views his lack of motivation as his greatest stressor. He is more open to therapy and discusses how his parents’ way of thinking also impairs his progress.

Plan

A male mentor has been arranged to meet with patient at least once a week to check on patient and also give patient an opportunity to have someone to share new information and progress with. Patient is also required to attend therapy session at least once a week and mother to monitor patient’s medication compliance.

Preceptor’s Reaction to Privileged Note

When I spoke with my preceptor about privileged notes, she said she does not use privileged notes and was not sure what I was referring to. After doing some research, she explained to me situations where privileged notes will be used and not included in their progress notes. She states that due to the number of patients she currently sees, the use of privileged notes will be cumbersome.

References

Elwyn, G., Dehlendorf, C., Epstein, R. M., Marrin, K., White, J., & Frosch, D. L. (2014). Shared decision making and motivational interviewing: achieving patient-centered care across the spectrum of health care problems. The Annals of Family Medicine, 12(3), 270-275.

Gaspersz, R., Nawijn, L., Lamers, F., & Penninx, B. W. (2018). Patients with anxious depression: overview of prevalence, pathophysiology and impact on course and treatment outcome. Current opinion in psychiatry, 31(1), 17-25.

Lombardi, D. R., Button, M. L., & Westra, H. A. (2014). Measuring motivation: Change talk and counter-change talk in cognitive behavioral therapy for generalized anxiety. Cognitive behavior therapy, 43(1), 12-21.

Ponsford, J., Lee, N. K., Wong, D., McKay, A., Haines, K., Alway, Y., & O'Donnell, M. L. (2016). Efficacy of motivational interviewing and cognitive behavioral therapy for anxiety and depression symptoms following traumatic brain injury. Psychological medicine, 46(5), 1079-1090.

Randall, C. L., & McNeil, D. W. (2017). Motivational interviewing as an adjunct to cognitive behavior therapy for anxiety disorders: A critical review of the literature. Cognitive and behavioral practice, 24(3), 296-311.